790 Annals Academy of Medicine Opioid Use amongst Cancer Patients at the End of Life—Lalit Kumar Radha Krishna et al Original Article Abstract Introduction: Concerns about the life shortening effect of opioids is a well known fact in the medical world when considering administration of these drugs for symptom alleviation at end of life. This study described the patterns of opioid use among cancer patients referred to a hospital-based specialist palliative care service for symptom management. This study also examined whether opioid use among terminally ill cancer patients during the last 2 days of life had any influence on survival. Materials and Methods: A retrospective review of case notes of patients who were diagnosed with terminal cancer and had passed away in a 95-bedded oncology ward between September 2006 and September 2007 was conducted. Data were col- lected on patients’ characteristics and patterns of opioid use including opioid doses and dose changes at 48 hours and 24 hours before death. Results: There were 238 patients who received specialist palliative care, of whom 132 (55.5%) were females. At 48 hours and 24 hours before death, 184 (77.3%) patients and 187 (78.6%) patients had received opioids, respectively. The median daily doses at 48 hours and 24 hours were 48 mg and 57 mg oral morphine equivalent doses (OME), respectively. Indications for opioid use were pain (41.1%), dyspnoea, (29.1%) and both dyspnoea and pain (30.8%). In the final 24 hours, 22.3% patients had a reduction in their mean opioid dose while 22.7% required an increase in their mean opioid dose. Increased age was associated with decreasing opioid doses (P = 0.003). Patients with spinal metastases required higher doses of opioids (P = 0.03) while those with lung metastases required lower doses (P = 0.011). Survival analysis using Kaplan-Meier survival curve revealed no significant survival difference between those who were on opioids and those who were not. Log rank test (Mantel-Cox) (P = 0.69). Conclusion: Our results showed that opioids are safe medications for symptom alleviation in terminally ill cancer patients during the last days of life and have no deleterious influence on survival. Ann Acad Med Singapore 2010;39:790-97 Key words: Palliative care, Survival analysis, Terminal cancer Opioid Use amongst Cancer Patients at the End of Life Lalit Kumar Radha Krishna, 1 MBBS, MRCP(UK), Jissy Vijo Poulose,²MBBS, M Med (Public Health), Benjamin SA Tan, 1 MBBS, Cynthia Goh, 1,2 MBBS, PhD, FAMS 1 Department of Palliative Medicine, National Cancer Centre Singapore ² Lien Centre for Palliative Care, Duke NUS Graduate Medical School Singapore Address for Correspondence: Dr Lalit Kumar Radha Krishna, Department of Palliative Medicine, National Cancer Centre Singapore, 11 Hospital Drive, Sin- gapore 169610. Email: Lalit.Krishna@nccs.com.sg Introduction Opioid use in terminally ill cancer patients at the end of life has been a source of concern amongst many for fear of its perceived life shortening effects, despite evidence to the contrary. 1-11 This fear has, in fact, contributed to the reluctance in utilising these drugs to provide adequate symptom relief to this group of vulnerable patients. There is a growing number of physicians who invoke the Doctrine of Double Effect (DDE) for moral reassurance when considering the administration of opioids. 11-16 DDE is used in medical practice as an ethical justification for a foreseeable harmful effect of a specific medical treatment when it is potentially beneficial for the patient and the clinician intends the best outcome. Patients as well as their families sometimes perceive the administration of opioids as an augur of a poor outcome. 13 Unsurprisingly, in actual practice, under-treatment of pain and distressing symptoms at the end of life still prevail. 17-21 Given their established efficacy and bioavailability, there is no denying that opioids are the drugs of choice at the end of life, to aid in the amelioration of symptoms like pain, dyspnoea and cough. 22,23 In fact, it has been shown that with close monitoring, safe and rapid pain control can be achieved even with significant increments in the daily opioid dose. 23-25 Previous studies from Japan, Israel and England have examined patterns of opioid use at end of life and its influence on survival. None of them have shown that opioid use affects survival or causes hastening of death. To the